ReliefWeb

Executive Summary

The ability of a population to access and consume nutritious, diverse foods in necessary quantities warrants particular attention as poor diets are a root cause of malnutrition in all its forms. A number of studies and surveys carried out in Timor-Leste over the past five years have sought to describe the nutrition situation in the country, identify challenges to ending hunger and improve nutrition and inform policy and programming both for multisectoral actions and for key target groups and sectors. One question that could not be answered through existing research was the extent to which availability of, access to and utilisation of nutritious foods impact food security and nutrition outcomes in Timor-Leste. As such, a Fill the Nutrient Gap (FNG) analysis was prioritised to investigate the following:

1. Determine the extent to which local food systems have sufficient diversity and quality to meet the nutritional needs of Timorese households.

2. Estimate how much it would cost to meet nutrient needs using local foods for individual population groups and households.

3. Estimate the extent to which households could afford nutritious diets.

4. Explore and compare the possible impact of multisectoral nutrition-specific and - sensitive programming on diet cost and affordability.

5. Equip KONSSANTIL and stakeholders to jointly prioritise recommendations for multisectoral programme and policy actions based on the key findings of the FNG analysis and the country’s existing evidence base.

The FNG in Timor-Leste was led by KONSSANTIL, within the Government of Timor-Leste (GoTL), with financial and technical support from national and international partners.
Importantly, the process brought together partners from across different sectors affected by/able to influence nutrition; health, social protection, agriculture, education and governance.

The FNG methodology is centred around diet modelling using the Cost of the Diet (CotD) analysis but goes beyond ‘diagnosing’ the problem by incorporating current programme and policy priorities, secondary data and technical support of the GoTL and partner organisations to model and estimate the impact of a range of multi-sectoral ‘actions’ to address malnutrition on the cost and affordability of nutritious diets. This FNG analysis aimed to provide further evidence on the possible effectiveness of already prioritised multi-sectoral nutrition actions in order to inform prioritisation of specific activities within these action areas in particular and, overall, contribute towards the review and reformulation of the next National Nutrition Strategy (NNS). The results will be important to help prioritise actions to guide programmes, policy and from advocacy. Key findings from the analysis are summarised in this section. These were considered by members of KONSSANTIL who prioritised a list of recommendations to take, also summarised below.

Nutrition has long been recognised as a fundamental human right in Timor-Leste and is incorporated throughout sector-specific and intersectoral policies. Evidence-based prioritisation of actions is now needed so feasible, affordable nutrition interventions are implemented across sectors. Nutrition Is a government priority in Timor-Leste and there are strong multi-sector policies that focus on nutrition as well as sector-specific policies that are nutrition-specific, with significant crossover across sectors. However, these policies need to be translated into implementation and implementing all listed actions may not be feasible due to shortages in budget and capacity. Strong evidence is needed to support KONSSANTIL to prioritise the many actions included in these policies and implement those that will likely have the greatest impact on improving diets and nutrition. KONSSANTIL sector priority interventions that were modelled to estimate possible impact on diet cost and affordability included micronutrient supplementation, provision of supplementary foods (Health) improvement to school feeding menus and inclusion of fortified rice (Education), the Bolsa da Mae cash transfer programmes and food vouchers (Social Protection), reduced post-harvest losses, improved production diversity and availability of nutritious foods (agriculture) and general food fortification. These interventions modelled span across sectors and lifecycle stages.

Diets are poor and non-diverse across Timor-Leste; especially for vulnerable groups such as mothers and children. Including a variety of foods from diverse food groups is essential for meeting nutrient requirements for all target groups. An adequate intake of a number of nutrients are required by all age and sex groups for physical and cognitive growth and development and to prevent disease. These nutrient requirements can only be met if nutritious and diverse diets are consumed. Contrarily, poor diets are a root cause of all forms of malnutrition, micronutrient deficiencies as well as underweight and obesity. Both the diversity and quality of diets in Timor-Leste are poor, for all groups in the population. Diets are generally based on starchy staple foods with low inclusion of vegetables and animal-source foods. This is especially the case for nutritionally vulnerable population groups such as women and young children. The FNG was carried out to investigate the extent to which some of this poor dietary attainment could be explained by the availability, cost of and access to nutritious foods.

Almost all Timorese households can afford to meet their energy needs but a nutritious diet that met the requirements of energy, protein and 13 micronutrients, would be unaffordable for most households. The FNG assessment revealed that a diet modelled in the CotD to meet energy requirements only for a household of five people 1 in the assessment municipalities would cost between $32-60 per month in Baucau, Bobonaro, Dili, Ermera, Manufahi and Oecusse. However, meeting nutrient needs would cost a lot more; diets modelled to meet the needs of energy, protein and 13 micronutrients would cost 4 times as much or $158 to $211 per month for five people. This would be significantly higher than the minimum wage of $115 per month.

The costs of these diets are not just determined by food prices in each municipality but also by the number and types of foods found in each municipality during the market survey and the nutritional needs of the model household members. Data on 98-128 foods were collected in each of the six assessment municipalities. Prices of meat, fish and eggs were generally 2-4 times as expensive as those of grains, legumes and vegetables.

The cost of meeting nutrient needs differed by age and sex groups; revealing the nutritional vulnerability of particular lifecycle stages. A nutritious diet would cost on average $2.58 for adolescent girls, $1.63 for lactating women, $0.78 for adult men, $0.41 for school children and $0.28 for infant children per day. Within this model household, meeting the nutrient needs of girls and women during adolescence and lactation would make up more than 70% of the total cost of meeting nutrient needs for the entire 5-person household. This is because there are particularly high micronutrient requirements for these groups during periods of growth and development. For example, while energy requirements for adult women and lactating women were similar, dietary iron requirements for lactating women are twice as high as those of adult men.

Modelled diet costs were compared to household food expenditure to estimate the extent to which they would be affordable to households across Timor-Leste. In general, all households (94%-100%) would be able to afford diets modelled to meet energy requirements only.
However, only few households (15%-37%) could afford nutritious diets. This means that interventions addressing the availability of and access to nutrients and nutritious foods, as well as purchasing power are needed to address poor diet access.

A number of interventions from different sectors were modelled in the FNG analysis, those targeting individual groups (supplementation, targeted food distribution, school feeding) and those targeting an entire household (agriculture, social protection, fortification).

Pregnant and lactating women (PLW), adolescent girls and infants and young children (IYC) are at particular risk of malnutrition in Timor-Leste due to high nutrient needs and low nutrient intake. The impact of the provision of Iron and Folic Acid (IFA) supplements or multiple micronutrient tablets (MMT) on the cost of meeting nutrient requirements for PLW and adolescent girls was modelled. The provision of supplements could halve the cost of meeting nutrient needs for PLW however MMT had a greater impact, reducing cost by an average of 60% on average compared to 40% for IFA, as it provides more nutrients. The potential impact of providing MMT was even greater for adolescent girls, reducing the cost of meeting nutrient requirements by an average of 70% compared to 40% for IFA. For IYC, multiple micronutrient supplements in the form of sprinkles were modelled; providing sprinkles for IYC in the complementary feeding period could reduce diet costs for this group by 40%. In contrast, providing a fortified supplementary food, super cereal/super cereal plus could reduce diet costs by 12% on average for PLW and 18% on average for IYC.

Alternative school meal menus were modelled for primary school children. The results showed that a greater percentage of nutrient needs could be met by increasing the budget for the Merenda Eskolar, selecting the most nutritious foods from the School feeding manual and including fortified rice, reducing the cost to the household of meeting nutrient needs of 65%-70% on average.

There is an opportunity to improve both the production and consumption of nutritious foods in Timor-Leste. The FNG modelled the possible impact of improving the production of a variety of nutritious foods such as eggs, green vegetables, beans and orange-flesh sweet potato and encouraging households to consume some of these foods instead of just selling them. In Baucau, for example, this could reduce the cost to households of meeting nutrient needs by 25%.

Current social protection transfers were also modelled. At present, the Bolsa da Mae transfer of $5 per child, per month (up to 3 children) would only cover a half of cost of providing a nutritious diet for an infant who is also breastfeeding, a third of the cost of a nutritious diet for a school child and one twentieth of the cost of meeting nutrient needs for an adolescent girl.
This modelling showed that these transfers are too low to have an impact on nutrition at present and that increased transfer amounts and conditionalities could assist to make them more nutrition sensitive.

The CotD modelling was also used to examine the combined impact of interventions from different sectors on overall household diet access. The results showed that it was possible to increase the percentage of households that would be able to afford a nutritious diet by an average of 250% if a package of well-designed interventions from multiple sectors (education, health, social protection and agriculture) were implemented. Conversely, if single interventions from one sector only were implemented the impact on household-level diet access would be limited.

These findings highlight that the responsibility for improving nutrition does not lie with one government sector alone (e.g. health), nutrition is instead something that can only be improved if all sectors act together, in a coordinated and complementary fashion. Based on the FNG results and through a process of dissemination workshops, KONSSANTIL members developed a set of recommendations for interventions to be prioritised across five (?) key sectors, as summarised in the following table. Given its leadership role in nutrition policy for Timor-Leste and the upcoming review of the National Nutrition Strategy, it is expected that these findings and recommendations will contribute to decision-making over the prioritisation of actions within future programmes.